Cambridge University Hospitals NHS Foundation Trust

4. Mrs O complains about the care and treatment the Trust provided to her in September 2023. She specifically complains nursing staff: • administered an excessive dose of intravenous immunoglobin (IVIG) and then failed to initiate post-error monitoring. IVIG is a treatment using antibodies from donated blood to boost the immune system • were dismissive of her concerns, did not verify the dose and lacked empathy with regards to her concerns.

5. Mrs O also complains about the complaint response. She said it lacks transparency, accountability and failed to classify the incident as a ‘NEVER’ event. A ‘NEVER’ event is a term used in healthcare to describe serious, preventable incidents that should not have happened.

6. Mrs O said this incident had a significant impact on her emotional wellbeing at the time. She was fearful of the consequences of the overdose, felt unsafe, unheard and powerless.

7. She has lost her faith in health staff to administer medication safely. She has found the constant vigilance of checking medication administration to be exhausting and emotionally draining.

8. Mrs O said the psychological impact has lasted beyond the incident itself. She continues to feel anxious. She said the Trust’s lack of accountability had added to her distress.

9. Mrs O is seeking an explanation, an apology, service improvements and financial remedy.

10. On 10 September 2023 the Trust admitted Mrs O to hospital.

11. On 27 September 2023 staff administered Mrs O with IVIG. The Trust has confirmed there was an error in the amount administered.

12. On 29 September staff submitted an incident report which was investigated by the pharmacy team and the senior sister.

14. Section 9(4) of the Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is good reason to do so.

15. We first considered when Mrs O became aware of her reason to complain, and whether her complaint was made to us in time.

16. Mrs O became aware of her concern in September 2023. This is when she realised the Trust had administered her with the wrong dose of IVIG.

17. Mrs O made her complaint to the Trust in a timely manner in October 2023.

18. The Trust responded to Mrs O in March 2024.

19. At the end of April 2024, we know Mrs O contacted us and spoke with our helpline. Notes indicate Mrs O had outstanding concerns. She was prompted to return to the Trust to see if these issues could be resolved before coming back to us. The call handler advised Mrs O about our twelve-month time limit on this call.

20. Mrs O followed this advice and contacted the Trust. It provided a further response to Mrs O in November 2024.

21. Mrs O brought her complaint to us in September 2025. This is nine months later.

22. We have considered Mrs O’s reasons for the delay in coming back to us after the response in November 2024.

23. Mrs O explained to us she had multiple complaints across three different NHS Trusts. It took her a significant amount of time to navigate multiple systems, policies and points of contact. She said this was made further difficult because she had to relive her experiences whilst going through the complaints processes.

24. We are sorry to hear and read about the number of issues and concerns Mrs O tells us she has experienced within different healthcare settings. We are sorry to hear she has had cause to make numerous complaints. We understand that doing so will have been challenging and time-consuming.

25. In this report, we are only considering her complaint about Cambridge University Hospitals NHS Foundation Trust (the Trust).

26. Mrs O explained the impact of making all her complaints is relevant to the delay in bringing this specific complaint to us.

27. She told us, in addition to navigating different complaint procedures, there was also some delay in the Trusts responding.

28. We can see it took the Trust five months to respond to her initial complaint, and then six months to provide a final response to her further complaint.

29. Mrs O also said she then invested months into preparing detailed, evidence-based emails outlining her concerns which she submitted directly to us. We advised her this was not the correct method for raising complaints.

30. We have a front-facing website which provide information about how to submit a complaint to us. We also do not ask complainants to investigate their issues before coming to us. It is not part of our complaint process, or a requirement of the complainant to provide evidence of failings to us.

31. Mrs O said she then needed a significant amount of time to complete 16 separate complaints across three different Trusts. She reiterated this required emotional resilience and concentration whilst managing her ongoing health issues. Mrs O said she understood she needed to submit all her complaints together.

32. She told her us health issues affect her energy, cognition and dexterity. We appreciate the impact these issues will have on administrative tasks.

33. Mrs O has also shared information about her accessibility needs. She told us she is visually impaired. She said her deteriorating eyesight has significantly affected her ability to manage written communication and documentation. She said this contributed to some of the delays in progressing her complaint. She said she is only able to write for a short period of time each day.

34. We are sorry to hear Mrs O’s eyesight is deteriorating and understand how concerning and frustrating this must be for her.

35. We have carefully considered the reasons Mrs O has given to us for the delay in coming to us. We acknowledge it was a difficult time, she was experiencing health issues, as well as navigating the complaints process with visibility needs. We acknowledge the length of time it took for the Trust to respond.

36. We have to balance this with the legal framework for what we can investigate and whether it is reasonable for us to investigate something that occurred some time ago.

37. We do not dismiss the challenges Mrs O has faced. We do not think we can robustly justify the nine month delay between Mrs O receiving her final response and coming to us.

38. We consider Mrs O could considered seeking support from an advocate if she was struggling to navigate different complaints processes, and to complete our complaint form. We had advised her in May 2024 about our time limit. Being aware of this, she could have come back to us sooner to request support to bring her complaint to us.

39. Part of Mrs O’s complaint is about the complaint handling. She received her final response in November 2024 before coming to us in September 2025. We consider this would fall in our time scale of one year.

40. Her concerns are largely about what the responses say. We would not be able to investigate those issues without looking at the treatment elements, which as detailed fall outside our time limit. We do not consider it would be practical or satisfactory to investigate this part of her complaint alone.

41. We appreciate the time and effort Mrs O put into making her complaint, particularly in light of the challenges she faced. We are sorry to disappoint her. We have decided we cannot legally investigate her complaint.

42. We wish her all the best for the future and hope she regains some confidence in the health services she needs to access.

1. We have carefully considered Mrs O’s complaint about Cambridge University Hospitals NHS Foundation Trust (the Trust). We are sorry to hear about Mrs O’s experience whilst under the Trust’s care. We understand how concerning and upsetting it was for her when she was administered the wrong dose of medication. We are sorry she felt nursing staff were dismissive of her concerns and lacked empathy.

2. We have decided we cannot look at Mrs O’s complaint further. This is because it falls outside of our time limit. We understand Mrs O’s health issues and reasoning for the delay in bringing her complaint to us. We do not think we can put our time limit to one side.

3. It is important we act within the law. We understand Mrs O will be disappointed with this decision. We do not intend for our decision to minimise her experiences or the impact she has shared with us. We hope this statement clearly explains why we will not be considering her complaint further.